Medical device with resuscitation prompts depending on elapsed time

ABSTRACT

Methods and apparatus are provided for determining a defibrillation treatment protocol in an external defibrillator using a measurement of elapsed time. The present invention provides a defibrillator with a timer function. Upon activation of the defibrillator, an internal timer begins to run. By closely associating the activation of the defibrillator with the onset of the patient&#39;s attack, and by making allowances for inherent time differences between these events, the timer provides a measure of the elapsed time between the onset of the patient&#39;s emergency and the presentation of the defibrillator at the patient&#39;s side. Using this measure of elapsed time, the defibrillator determines an appropriate treatment therapy, such as CPR or defibrillation therapy.

FIELD OF THE INVENTION

The present invention generally relates to external defibrillatorsincluding Automatic External Defibrillators (AEDs), and moreparticularly relates to interactive defibrillators havingcardiopulmonary resuscitation (CPR) prompts for patient treatment. Stillmore particularly, the present invention relates to methods ofcoordinating resuscitation prompts with the time elapsed from theactivation of the AED.

BACKGROUND OF THE INVENTION

A normal human heart pumping pattern is called a sinus rhythm, and isregulated by the body's biological pacemaker within the upper rightchamber of the heart, which is commonly referred to as the right atrium.This natural pacemaker, which is generally referred to as the sinoatrial(SA) node, sends electrical signals to the right and left ventricularmuscles in the lower chambers of the heart. The ventricular muscles thenimplement the pumping action under control of the SA node. The rightventricular muscle pumps blood to the lungs for oxygenation, and theleft ventricular muscle pumps the oxygenated blood to various parts ofthe body.

In certain circumstances, the normal or sinus heartbeat rhythm may beadversely affected as a result of some type of malfunction in theheart's electrical control system. When this type of malfunction occurs,an irregular heartbeat may result, causing the ventricular muscles topump ineffectively, thus reducing the amount of blood pumped to thebody. This irregular heartbeat is generally referred to as anarrhythmia, which can also lead to Sudden Cardiac Arrest (SCA).

It is estimated that approximately two hundred and twenty-five thousand(225,000) deaths per year are attributable to SCA. A particularlyserious type of SCA is known as Ventricular Fibrillation (VF), which isa malfunction characterized by rapid, uncoordinated cardiac movementsreplacing the normal contractions of the ventricular muscles. In thisevent, the ventricular muscles are not able to pump blood out of theheart, and there is no initiation of a heartbeat. VF rarely terminatesspontaneously, and is therefore a leading cause of sudden cardiac death.The unpredictability of VF and other irregular heat beat conditionsexacerbates the problem, and emphasizes the need for early therapeuticintervention to prevent the loss of life.

Defibrillators are devices for providing life-saving electrical shocktherapy to persons experiencing an irregular heat beat, such as VF. Adefibrillator provides an electrical shock to the heart, in order toconvert the irregular heart beat to a normal sinus rhythm. One type ofdefibrillator is surgically implanted in patients who are consideredlikely to need electrical shock therapy, precluding the necessity ofconstant monitoring by medical personnel.

Another commonly used type of defibrillator is the externaldefibrillator, which sends electrical shock pulses to the patient'sheart through external electrodes applied to the patient's chest.External defibrillators may be manually operated, as are typically usedin hospitals by medical personnel or may be semi-automatic,semi-automated, fully automatic, or fully automated devices, where theycan be used in any location where an unanticipated need may occur. Anautomatic external defibrillator is commonly referred to as an AED.

It is well known that time is an important factor in the successfulapplication of electrical shock therapy. The survival rate of personssuffering from VF decreases by about ten percent (10%) for each minutethe administration of a defibrillation shock is delayed according tosome data. It is therefore desirable to minimize the time durationbetween powering up an external defibrillator and administering theelectrical shock therapy to the patient. It is also estimated that therate of survival for SCA victims averages less than two percent (2%)when defibrillation is delayed ten (10) minutes or more.

In a typical usage of a defibrillator, the defibrillator electrodes areattached to the patient prior to delivery of a defibrillation shock. Thedefibrillator can also monitor the patient's condition and parameters.This data can be measured and analyzed, and then a defibrillationcircuit can be determined based on that analysis. The defibrillator thencharges to an appropriate level and applies the shock therapy in adesired format. One or more of these activities can be done bymedical/emergency personnel, as in the case of manual defibrillators, orby an automatic or automated process, as in the case of automatic,semi-automatic, automated and semi-automated defibrillators. Theseactions, while necessary, can also be disadvantageously time-consuming,and can delay the administration of the shock therapy.

Additionally, some defibrillators have been developed that integrate CPRinstructions along with shock treatment. CPR is a combination oftechniques including artificial respiration (rescue breathing) andartificial circulation (chest compression). One purpose of CPR is toprovide oxygenated blood through the body, and to the brain, in thosepatients where a prolonged loss of circulation places the patient atrisk. For example after a period of time without restored circulation,typically within four (4) to six (6) minutes, cells in the human braincan begin to be damaged by lack of oxygen. In some cases, shock therapydoes not immediately restore a normal heart rhythm; several shocks maybe required. In other cases, CPR should be administered prior to anydefibrillation therapy. Thus, different patient conditions may requiredifferent combinations of shock therapy and CPR therapy. For example,some patients may only need shock therapy while others may use bothshock therapy and CPR. Further, different patients may benefit thecombination of CPR and defibrillation in different order. Some maybenefit from CPR first, followed by defibrillation; and other differentpatients may benefit from defibrillation first. It would be desired todevelop a defibrillator and defibrillation system that can quicklydetect and order a patient's therapy needs.

Many defibrillators also include a CPR protocol. A CPR protocoltypically uses voice prompts and/or a form of interactive display, thatguides a user in when to apply CPR methods and shock therapy. ACPR-first protocol has been proposed for use with some defibrillationdevices. Under this protocol, the defibrillator is configured to promptCPR therapy as the first type of therapy to be given a patient. In sucha device the defibrillator may also include ECG (electrocardiogram)capability in order to monitor patient conditions. One example of anexternal defibrillator with CPR prompts is described in U.S. Pat. No.6,356,785. Another is U.S. Pat. No. 6,334,070. The CPR protocol includesprompts which indicate when CPR should be applied. The prompt may be inthe form of a visual/graphical display, an audio display, or some otherform of communication.

While it is advantageous to integrate CPR and shock therapy, there areinstances in which CPR first, prior to shock therapy, is not theappropriate patient treatment. Rather, shock therapy should beadministered first, and any delay in doing so is potentially adverse tothe patient. Nevertheless, in those systems that have a defaultCPR-first protocol, it is typical that a user first pass through the CPRprompts in order to reach the shock treatment. Thus, it would be desiredto provide a defibrillator that allows for an appropriate selectionbetween a CPR therapy and defibrillation therapy.

Additionally, in those situations in which the defibrillator has beenbrought to the side of an emergency patient quickly, the small amount oftime elapsed generally indicates that defibrillation should first beapplied. Thus, time is an important factor in determining a preferredtreatment protocol, the time between the onset of the patient attack andthe presentation of the defibrillator to the patient. Thus, it wouldalso be desired to provide a defibrillator that can account for the timeelapsed between the beginning of a patient emergency and the evaluationof a defibrillator therapy.

Moreover, there are delays inherent in the CPR protocol that maydisadvantage certain patients. Algorithms for determining which patientsshould receive CPR first have several problems. First of all, theyrequire time to acquire the signal (from the patient) and additionaltime to perform an analysis of the data. This time delays therapy.Although the delay may presumably be small, nevertheless, there are someindications that even small delays can be important for patienttreatment.

Secondly, ECG analysis algorithms generally require high-powered CPUs toperform the required analysis in a reasonable amount of time. This addscost to the product. For some consumers, the added cost may deter theacquisition of a defibrillator as part of the emergency equipment to bekept on hand. Thus, because AEDs are cost-sensitive products, it wouldbe desired to find ways to minimize their cost.

Finally, ECG analysis algorithms have not been shown to work better thana simple timer when it comes to determining whether to perform CPR priorto defibrillation. An estimate of the patient's down time is valuabledata that is relatively simply processed for determining whether toperform CPR prior to defibrillation.

Thus, it would be desired to develop a defibrillator with a treatmentprotocol that takes into account time factors in treatment. For thosesituations in which only a small amount time has elapsed between thepatient suffering an emergency and the presentation of the defibrillatorto the patient, the defibrillator can immediately follow adefibrillation protocol without the need to consider CPR treatment.

Hence there exists a need for an improved defibrillator and an improvedmethod for operating a defibrillator. Namely, there is a need for adefibrillator, and especially an external defibrillator, that addressesone or more of the above-noted, and other not explicitly or implicitlymentioned, drawbacks and limitations. It would be desired to provide adefibrillator and a control system thereof that reduces the inherenttime delays associated with shock administration in externaldefibrillators and/or a defibrillator and method of operating adefibrillator that accounts for the time between the onset of a patientemergency and the presentation of defibrillation means to the patientand/or a defibrillator and method of operating the same that usesrelatively simple analytic methods involving time in determining a CPRor defibrillation treatment protocol. In addition, it would be desiredto provide a defibrillator that includes convenient interactive featuresso that output and input can be quickly received and supplied by a humanoperator/user. Finally, it would be desired to provide a defibrillatorthat, by virtue of the foregoing, offers an improved level of responseand patient treatment. The present invention addresses one or more ofthese needs.

BRIEF SUMMARY OF THE INVENTION

The present invention provides a defibrillator with a timer function.Upon activation of the defibrillator, an internal timer begins to run.By closely associating the activation of the defibrillator with theonset of the patient's attack, and by making allowances for inherenttime differences between these events, the timer provides a measure ofthe elapsed time between the onset of the patient's emergency and thepresentation of the defibrillator at the patient's side. Using thismeasure of elapsed time, the defibrillator determines an appropriatetreatment therapy, such as CPR or defibrillation therapy.

In one embodiment, and by way of example only, there is provided amethod for determining a defibrillation treatment protocol comprisingthe steps of: activating a defibrillator; starting a timer within thedefibrillator; attaching electrodes of the defibrillator to a patient;sampling the timer to obtain an elapsed time; comparing the elapsed timeto a TMIN; ordering a CPR treatment protocol if the elapsed time isgreater than the TMIN; and ordering a shock treatment protocol if theelapsed time is less than the TMIN. The method may also comprise theadditional steps of performing a shock analysis under the shocktreatment protocol; ordering a CPR treatment protocol if shock treatmentis not indicated by the shock analysis; and issuing a defibrillationshock if shock treatment is indicated by the shock analysis. The step ofactivating the defibrillator may include acts such as removing thedefibrillator from a wall mount, manually turning on the defibrillator,or receiving a signal (such as a wireless signal or a signal on a dataline) from an EMS center. The method may also include sampling the timera second time to obtain a second elapsed time and then comparing thesecond elapsed time to the TMIN.

In a further embodiment, and still by way of example, there is alsoprovided an external defibrillator for providing a selected treatmentprotocol to a patient comprising: a plurality of electrodes affixed tothe defibrillator and capable of being attached to a patient so as toprovide shock therapy; a plurality of sensing electrodes affixed to thedefibrillator and capable of being attached to a patient so as toprovide patient data to the defibrillator; an input device disposed onthe defibrillator; an output device disposed on the defibrillator; and acontroller disposed in the defibrillator, where the controller iscoupled to the plurality of electrodes, the plurality of sensingelectrodes, the input device, and the output device, and wherein thecontroller is also configured to: start a timer function uponactivation; sense when the sensing electrodes are attached to a patient;sample an elapsed time from the timer function; compare the elapsed timeto a set time; order a CPR protocol if the elapsed time is greater thanthe set time; and order a shock treatment protocol if the elapsed timeis less than the set time. The elapsed time may be output through theoutput device so as to be readable by a human user. Additionally, thedefibrillator may include an override function configured within thecontroller that immediately selects a shock protocol when it isselected. In another feature, the defibrillator controller is furtherconfigured so as to sense a patient connection and then to sample anelapsed time upon sensing the patient connection. The defibrillator mayalso have a power on mode and an automatic power off mode; the timerfunction may continue to operate for a period of time after thedefibrillator passes from power on mode to power off mode. Thedefibrillator may also include a low power circuit wherein the timerfunction operates through the low power circuit. The defibrillator mayfurther include non-volatile memory such that the controller is furtherconfigured to: record a start time upon activation; store the start timein non-volatile memory; sample a second time; and calculate an elapsedtime by comparing the second time with the start time. Also, thedefibrillator may include a real-time clock function wherein the starttime is recorded by sampling the clock time and wherein the second timeis also recorded by sampling the clock time. The defibrillator can alsobe configured such that the controller senses a patient connection andalso senses whether CPR is being administered to the patient; and thecontroller is further configured to order a shock treatment protocolupon sensing that CPR is being administered to the patient.

Other independent features, characteristics, and advantages of thedefibrillator with a timer function will become apparent from thefollowing detailed description, taken in conjunction with theaccompanying drawings which illustrate, by way of example, theprinciples of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an illustration of an external defibrillator system connectedto a patient in accordance with an exemplary embodiment of the presentinvention.

FIG. 2 is a simplified block diagram of an external defibrillator systemin accordance with an exemplary embodiment of the present invention.

FIG. 3 is a simplified flow chart showing a first exemplary embodimentof a protocol selection method using a timer input configured in anexternal defibrillator.

FIG. 4 is a simplified flow chart showing an embodiment of cooperationbetween a CPR treatment protocol and a defibrillation treatmentprotocol.

FIG. 5 is a schematic view showing an activation of a defibrillator witha timing function according to an embodiment of the present invention.

FIG. 6 is a simplified flow chart showing a user input time adjustmentto the defibrillator timer function according to an embodiment of thepresent invention.

FIG. 7 is a simplified flow chart showing the override function to thedefibrillator timer function according to an embodiment of the presentinvention; and

FIG. 8 is a simplified flow chart showing a decision tree for patienttherapy configured in a defibrillator that involves three patienttherapies and two threshold times, according to an embodiment of thepresent invention.

DETAILED DESCRIPTION

The following detailed description of the invention is merely exemplaryin nature and is not intended to limit the invention or the applicationand uses of the invention. Furthermore, there is no intention to bebound by any expressed or implied theory presented in the precedingbackground of the invention or the following detailed description of theinvention. Reference will now be made in detail to exemplary embodimentsof the invention, examples of which are illustrated in the accompanyingdrawings. Wherever possible, the same reference numbers will be usedthroughout the drawings to refer to the same or like parts.

Referring now to FIG. 1 there is shown a typical defibrillator system 10that may be used in embodiments of the present invention. The system 10is configured to deliver a defibrillation shock to a patient 12, such asa victim of VF. The defibrillator system 10, includes, but is notlimited to, an external defibrillator 11 having a connection port 13that is configured to receive one or more electrodes (14, 15). (Adefibrillator may have more than one connection port). The externaldefibrillator 11 can be any number of external defibrillators inaccordance with the present invention. For example, the externaldefibrillator 11 can be an Automatic External Defibrillator or AutomatedExternal Defibrillator, semi-Automatic or semi-Automated ExternalDefibrillator, or a manually operated external defibrillator. U.S. Pat.No. 4,610,254 to Morgan and U.S. Pat. No. 6,334,070 to Nova provideillustrative examples of defibrillators, and these two patents arehereby incorporated in their entirety by reference.

The external defibrillator 11 preferably includes a user interface 17.The interface 17 may include an output device such as a display 18 thatis configured to visually present information which may include variousmeasured or calculated parameters of patient 12 and/or other informationto the operator (not shown) of the external defibrillator 11. Display 18is capable of providing information in textual, numeric, graphical,and/or symbolic format. Information may also be output from thedefibrillator through other means such as but not limited to audiblesignals and/or voice prompts through a speaker or other audio generationdevice. When a display 18 is included, it may comprise any number ofdisplay configurations, e.g., Liquid Crystal Display (LCD) or ActiveMatrix Liquid Crystal Display (AMLCD). Other output devices are alsopossible such as LED's and other light indicators. In some embodiments,a printer may also be included for creating hard copies of data. In apreferred embodiment, display 18 provides prompts or instructions to auser related to a treatment protocol. Thus, for example, display 18 mayprovide CPR instructions and/or shock defibrillation instructions.Display 18 may also provide queries or prompts to input informationwhich are further used in analyzing or selecting a treatment therapy.

The user interface 17 can also include one or more input devices 16 thatare configured to receive commands or information from the operator.Input devices may include, but are not limited to, devices such as keys,buttons, switches, touch screens, keyboards, and keypads. The device mayalso be configured to receive input electronically such as via radiosignals, electrical signals, and digital transfer of information. Thus,for example, in some embodiments, the defibrillator receives input fromsensing electrodes positioned on patient 12. In one embodiment, thedefibrillator is additionally configured to receive input in the form ofhuman voice commands. Thus a receiving device such as a microphone isincluded, along with the necessary means to convert voice signals torecognizable controller commands. In a preferred embodiment, inputdevices 16 include antennas and other equipment necessary to receivewireless communication as well as connections so as to receive datalines for the transfer of information.

Electrodes 14, 15 are typically multifunction electrodes in that theyare configured both to provide defibrillation therapy and to sense oneor more physiology and/or physical parameters of the patient 12 that arereceived by the external defibrillator 11 at the connection port 13.This is a typical configuration in an AED type device; it will beunderstood by those skilled in the art that electrodes may be designeddifferently for different machines. Other defibrillators, including forexample manual defibrillators, may also have an additional set ofelectrodes (not shown), in addition to the multifunction electrodes,used to receive ECG information. These additional electrodes, ECGelectrodes, are generally smaller than therapeutic/multifunctionelectrodes, and ECG electrodes typically plug into a separate port (notshown) than the therapeutic/multifunction electrodes. As is understoodin the art, ECG electrodes typically have a three wire lead, thoughother arrangements are possible. The signals provided by the one moreelectrodes (14,15) are preferably evaluated by the externaldefibrillator 11 to determine, among other things, whether adefibrillation shock should be applied to patient 12 in accordance withtechniques known to those of ordinary skill in the art. This externaldefibrillator 11 can, in some embodiments, also evaluate the signalsprovided by the one more electrodes (14, 15) to determine the waveformparameters of the defibrillation shock (e.g., sinusoidal, monophasic,biphasic, truncated) as well as magnitude and duration; AEDs ofteninclude a preprogrammed energy protocol. As is understood in the art,manual defibrillators may allow for a manual selection of shockparameters.

A variety of physiological data and signals of the patient 12 can besensed by the defibrillator. For example, conventional phonocardiogram(PCG) transducers can be used to convert acoustical energy of thepatient's heart to electrical energy for production of a PCG waveform.Additionally, electrical activity of the patient's heart can beconverted for production of an electrocardiogram (ECG) waveform.Transthoracic impedance and other physiology signals of the patient mayalso be detected. This data represented by this information can becollected and processed in the controller of the defibrillator.

Referring to FIG. 2, a simplified block diagram of the externaldefibrillator 11 is illustrated in accordance with an exemplaryembodiment of the present invention. The external defibrillator 21preferably includes a controller 21, the user interface 17 (e.g.,switches or buttons 16 and/or display 18 as shown in FIG. 1), apre-amplifier/measuring circuit 22, a charging mechanism 23 that caninclude a power source 24 and a switch 25 to couple the power source 24to the one or more energy storage devices (e.g., capacitors) 26 and anenergy delivery circuit 27, which is illustrated as a switch 28 that isconfigured to selectively couple the one or more energy storage devices26 to the connection port 29 under the control of the controller 21. Theenergy delivery circuit 27 can be implemented with any number of circuitconfigurations. For example, in a biphasic circuit, an H-bridge circuitcan be used in accordance with the present invention. The controller 21can be a single processing unit or multiple processing units and can beimplemented with software, hardware, or a combination of hardware andsoftware. The controller 21 is configured to at least partially controlthe operation of the external defibrillator 11, including control ofcharging the one or more energy storage devices 26. Controller 21further controls input and output to the device, including displaymethods, and any sequencing of queries and responses.

An AED is generally designed for use by a “first responder,” a user whowould typically be the first person to arrive on the scene of a medicalemergency. A first responder may be a layperson with minimal or no AEDtraining. AEDs are being made to be interactive so as to be able toprovide a level of guidance to a first responder. This has been foundparticularly useful with those devices designed for use by laypersons,or others with minimal emergency response training.

It has now been discovered that a defibrillator, including particularlyexternal defibrillators and AEDs, can be configured to include a timerfunction. The timer function calculates an elapsed time that provides aclose approximation of the time between the onset of a patient emergencyand the presentation of the defibrillator at the patient's side readyfor service. The defibrillator uses this time information, in whole orpart, to determine a treatment therapy.

Referring now to FIG. 3 there is shown a simplified flow chart whichillustrates a first exemplary embodiment of a defibrillator with a timersensitive treatment selection. The steps shown in the embodiment wouldpreferably be configured into the controller of a defibrillator. Theflowchart of FIG. 3 represents a simplified embodiment, and as will befurther elaborated, various additional steps, modification, and/oralternate configurations may be added to this process.

In a first step 30, the device is activated. This activation can be donein a number of ways, some described in more detail below. In thisembodiment, the activation is as simple as powering or turning on thedevice. Thus a device may have a power on and power off states or modes.

Once the defibrillator is activated, a timer begins, step 31. The timerrecords elapsed time beginning with the defibrillator activation. Thetimer records time through a timer function, which is known in the art.A timer function is a program, or controller configuration, thatmeasures time, in this case from a start point. An electronic clock ortimer may be included in the timer function. Values of elapsed time areable to be sampled for use in other routines of the system. A preferredembodiment of the timer function measure up time, elapsed time beginningfrom a starting point. The timer function may also be configured to be adown counter which begins with a starting value and counts down to zero.Thus, where actions are described herein as being triggered uponreaching a time value, it will be understood that that may be either apositive time value reached through an up counter or a zero (or other)time value reached through a down counter.

As the defibrillator is further used, it is brought to a patient.Eventually, the electrodes of the defibrillator are then attached to thepatient, step 32. At this point the defibrillator begins receivinginformation from the patient, through the electrodes. Also, at thispoint, the defibrillator (or more particularly, the processor thereof)begins to analyze information and may suggest a treatment protocol.

After electrodes are attached to the patient, the defibrillator samplesthe timer, step 33. That is, the current elapsed time as measured by thetimer (initiated in step 31) is input or read into the controller. Thatdata point, the elapsed time, is then subjected to a query in step 34.It is determined whether the elapsed time is greater than or less than(or also equal to) some set time, TMIN. If the elapsed time is greaterthan TMIN, then the defibrillator orders a CPR protocol. If the elapsedtime is less than TMIN, a defibrillation protocol is ordered. (Cases inwhich TMIN is equal to the elapsed time may be set to follow one or theother protocols.)

In a further embodiment, the defibrillator may prompt the timersampling, step 33, once the defibrillator senses it is attached to thepatient. The patient connection can be sensed via one of several knownmethods including receiving data through the defibrillation electrodes,the ECG electrodes, a pulse oximetery probe, a blood pressure cuff, or apulse detection sensor.

In one embodiment, the clock can be stopped once the electrodes areattached to the patient in step 32. The single clock reading that occursat that time dictates the sequence of treatment protocols that thedefibrillator prompts at that point. However, in another embodiment thetimer is not stopped; rather after a time sampling, step 33, the timercontinues to run. Additional time samples can be taken at future pointsto provide additional time information used in making treatment protocoldecisions. Thus, for example, when the defibrillator continues to taketime samples, once the time sample is greater than TMIN, thedefibrillator then orders a CPR protocol rather than a defibrillationprotocol. Also, in another embodiment, time samples, along with datataken from the patient, drive routines that indicate a treatmentprotocol.

As is understood in the art, the individual treatment protocols, the CPRprotocol of step 35 and the defibrillation protocol of step 36, maythemselves comprise a number of steps. Further, each of thedefibrillation protocol and CPR protocol may cooperate with each other.Referring now to FIG. 4 there is shown a flow chart that describes oneembodiment of an interaction between a defibrillation protocol and a CPRprotocol. This flowchart begins with step 36 from FIG. 3; there adefibrillation protocol has been selected and ordered by thedefibrillator. In the defibrillation protocol there follows a next stepof performing an analysis of the patient's ECG to determine if adefibrillating shock should be delivered (referred to as “shockanalysis” in this document), step 41. Based on data received from thepatient, the defibrillator runs algorithms to determine whetherdefibrillation therapy is warranted, step 42. If a defibrillation isindicated by that analysis, in a next step the defibrillator administersdefibrillation therapy, step 43. There may then follow a furtheranalysis which indicates additional defibrillation therapy, or perhapsCPR therapy. If, however, the initial shock analysis, step 42, does notindicate that defibrillation therapy is warranted, then the system willrevert to the CPR protocol, step 44. The CPR protocols typically includea set of prompts or instructions (output) that communicate with a userto perform steps such as heart massage (chest compression) or artificialrespiration (rescue breathing) for a number of repetitions and for acertain length of time. Further step 43, the step in whichdefibrillation therapy is administered, may also include sub-steps ofdetermining the appropriate level and form of defibrillation therapy asdescribed before.

As was previously stated, various configurations of a defibrillator canbe integrated with the defibrillator process shown in FIG. 3. Forexample, the activation step, step 30, may be initiated or otherwise maytake place, in various ways. In one embodiment, a defibrillator ismanually activated for example by depressing a switch.

In another embodiment, a defibrillator is a wall mounted defibrillator.The defibrillator may be configured so that the act of pulling thedefibrillator from the wall is the initiation step. Thus, the timerwould begin to run from the first user contact with the device,typically an early moment during an emergency. By linking the timer withwall removal, the timer better approximates an actual elapsed time fromthe first moment of the emergency. The physical act of removing thedefibrillator from the wall may also be linked to a depressing of somebutton or the completion/breaking of some circuitry that is part of thedefibrillator so as to power on or activate the defibrillator. It wouldbe within the level of skill in the defibrillator art to devise a meansthat links the act of pulling a defibrillator from the wall to anactivation of the device.

While a wall mount is a typical placement for an AED, other locationsare also possible, such as storage in a box, kit, or at an emergencystation. Thus, an act of removing the AED from its place of rest/storage(other than a wall) may also give rise to activation as in the wallmount scenario. In one alternative, a defibrillator may be provided witha mechanism to detect when the defibrillator is put into motion, and amechanism to start the timer when that motion is first detected. Forexample, a motion-sensitive switch could be used to start the timer whenthe defibrillator is put into motion (by, for example, being picked upby a user) or an accelerometer which would output a signal when thedefibrillator starts moving, which in turn starts the time intervalmeasurement. In an alternative embodiment, the timer could be startedwhen a user first touches the defibrillator by incorporating into thedefibrillator capacitive touch detection techniques (like those used intouch-activated lamps, for example), microswitches or other techniquesand devices well-known to those who design external defibrillationdevices. In embodiments such as these, the timer may be started prior toactivation of the defibrillator.

In a further embodiment, the activation step, step 30, takes place inconjunction with a call to an emergency service. Again, linking theactivation step to the emergency call closely aligns the timerinitiation, step 31, to the actual time when the emergency began. Now,the means by which the activation step 30 is linked to the emergencyservice notification may vary. For example, in one embodiment, an EMSresponder may physically activate the defibrillation device uponreceiving an emergency notification. However, preferably, there isprovided some automatic link between an emergency call and activation ofthe device 30. In this kind of system a call to an EMS center triggers asignal, and the signal in turn activates the defibrillator. Thistriggering mechanism can take the form of a wireless radio signal, ahard communication link, or even a computer command, among other forms.

Referring now to FIG. 5 there is illustrated an exemplary embodiment ofa system that includes an automatic activation feature. An emergencyevent is first reported by a member of the public by a call over a phoneline 51. The emergency call is made to a local emergency responder suchas an EMS center 52. A hard line is indicated in the figure, butwireless calls are also to be included therein. The EMS center 52records the time at which the call is first received along with otheremergency information as part of the intake process. The time the callwas received will eventually become the start time for the timerfunction in the defibrillator. Upon receiving information, including thecall time, from the caller, the EMS center 52 transmits emergencyinformation to an emergency responder, such as fire station 53. The firestation 53 in this case would be selected by EMS criteria including, forexample, the proximity to the patient. The communication link betweenthe EMS center 52 and the fire station 53 may include various means suchas, but not limited to, wireless communication 54 or data line 55. Wherewireless communication is utilized, enabling means such as hardware,software, antennas and transferring ground lines may not be illustrated.In one preferred embodiment, fire station 53 receives emergencyinformation through a computer 56 that is in turn connected todefibrillator 57. Emergency information received at the fire stationincludes a signal that is passed on to and activates the defibrillator57. Within the fire station itself various means may be configured bywhich to relay an activation signal, along with the start time, to thedefibrillator. Two are illustrated, and they include wirelesscommunication 58 and data line 59. An activation command may be relayedto the defibrillator through a wireless signal or through the data line.Alternatively an activation command may be generated by an emergencyresponse computer located in the fire station, or in some otherlocation. In a preferred embodiment, a wireless communication 58activates a defibrillator 57 located on a vehicle, such as a fire truckor ambulance. In this way, a defibrillator 57 may be prepositioned onthe emergency response vehicle and there is thus no delay in retrievinga defibrillator and bringing it to the vehicle. The signal to thedefibrillator carries information both to activate the defibrillator andto convey the start time of the emergency. In a further embodiment, aninitial time value is downloaded from the dispatch center 52 todefibrillator 57. In this embodiment, the signal transmitted from theEMS center 52 may also include information that provides an initial timevalue.

It will be appreciated that in emergency situations, the time at whichthe medical emergency takes place (e.g., the onset of VF) may notcorrespond precisely with the activation, step 30, of the defibrillator.For a variety of reasons, there may be some delay between these events.Just to list a few, the patient suffering an attack may not be observedor noticed for some time period. Alternatively, where an EMS call isinvolved, there may be some delay in making that call. Thus, for anumber of reasons, it may be desired to adjust the timer function in thedefibrillator to account for this inherent delay. There are various waysto allow for such a time adjustment.

In one embodiment, a time adjustment is provided by presetting the TMINvalue with some quantity that provides a built-in adjustment. Forexample, certain medical data indicate that in ideal situations the TMINvalue should be set at approximately 5 (five) minutes, i.e., CPR shouldbe applied first when defibrillation capability is brought to a patientmore than five minutes from the onset of VF. This is the idealsituation, TMIN=5 min. However, empirical and practical evidence mayindicate that there is an average delay of one (1) to two (2) minutesbetween the onset of VF and the average emergency response. In such asituation the TMIN may be set at three (3) to four (4) minutes to allowfor the inherent delay. Of course, other values for the ideal responsetime as well as the time offset therefrom may be used that differ fromthe exemplary values discussed in this paragraph.

In another embodiment, the time adjustment is provided, not to TMINvalues, but to the timer function. This may include commencing the starttimer step, step 31, at some value greater than zero. For example, thestart timer step may begin with a start time value of one (1) minute, orsome other value. This offset to the start time corresponds with anydelay that is desired to be adjusted.

In still another embodiment, the means to provide a time adjustmentallows for the user to input an adjustment to the timer function. Thedefibrillator is configured so as to allow a user to input some valuethat serves as a time adjustment. In this manner a value can bedetermined that accounts for a desired time offset. The value may serveas either an adjustment to the TMIN value or to the time recorded by thetimer function. The input may be submitted in response to a query orprompt generated by the system. The user may alternatively command thedevice to accept an adjustment. Various input devices, described above,may be used for making this adjustment. In a different embodiment, thevalue for TMIN is not preset, rather the TMIN value is input into thedefibrillator system. Thus, it is preferred that the defibrillator beprogrammable with respect to TMIN values. Additionally, whereinformation is provided to the defibrillator through an EMS center, theinformation transmitted by the EMS center to the defibrillator mayinclude time adjustment information.

An illustration of an embodiment of the programmable time adjustment isillustrated in FIG. 6. In a first step, step 61, the defibrillatorissues a prompt that asks for a time adjustment. The prompt may be agraphical output such as “INPUT RESPONSE TIME ADJUSTMENT”. If the userresponds, he does so in step 62 where a time adjustment is input. Thedefibrillator receives the input time adjustment, step 63. In thisembodiment, the time adjustment amount is deducted from the TMIN value.The system further makes allowance for the situation in which no timeadjustment is input. In that event, step 64, the system uses a presetTMIN value.

Still another means for making a time adjustment allows for a timeadjustment by virtue of patient data. Once defibrillator electrodes areattached to the patient, the device begins to receive patient data, asis known in the art. Certain data may indicate that the true time fromthe onset of the medical emergency does not correspond with the timepresently measured by the timer function. An appropriate time adjustmentmay then be automatically input into the system.

Finally, with respect to time adjustments, it is noted that more thanone, or even all, of the above-discussed means to make time adjustmentsmay be combined in a single device.

In one embodiment, the timer-based algorithm may be overridden. This maybe appropriate where, for example, bystander CPR has been administeredto the patient at the time the defibrillator is brought to the patient.Thus, in a preferred embodiment, the defibrillator includes a button orother input device that allows for a user to opt out of the timer-basedtreatment decision-making routine. FIG. 7 is a flow chart thatillustrates the override function. Activating the override input, step71, orders the controller to proceed directly to a shock treatmentprotocol, step 36. Further, the defibrillator may automatically overridethe timer algorithm where it detects that CPR is being applied to apatient when defibrillator connection with the patient is sensed. Theseembodiments may be useful in those situations where, for example, afirst responder without a defibrillator begins to administer CPR to astricken person. Later, the defibrillator is brought to the emergencyscene and is attached to the patient. It is not necessary that thedefibrillator determine whether or not a responder should apply CPRbecause CPR has already been, and is being, administered to the patient.Thus, the defibrillator is commanded to bypass the decision routine, or,the defibrillator senses that CPR is being administered andautomatically bypasses the timer routine.

Some AEDs automatically turn off their own power if they are not usedwithin a specific amount of time. And correspondingly, the AED also hasa power on and a power off mode. This automatic turn off is typicallydone in order to avoid unnecessarily draining the batteries. However,such an automatic power-off feature may interfere with the operation ofthe timer function. In order to avoid inappropriately resetting theresponse timer due to the power-off feature, an AED should continue tomaintain the timer for a period of time even if the remainder of theunit has powered off. In one embodiment, the timer could operate througha low-power circuit that remains active even in the power-off mode.Alternatively, a real-time clock function could be used as part of thetimer function. The time of day could be stored in non-volatile memory(which requires little or no power) as a start time when the timerfunction is started. Later, the elapsed time can be calculated by againsampling the real-time clock and comparing the newly sampled time withthe start time. In still another embodiment, the defibrillator couldinclude an activation mode that turns on the response timer function,but allows the remainder of the device to remain powered off. Later,when the device is ready for use with the patient, the remainder of thedevice may be activated.

While the timer function as described herein has particular use withrespect to defibrillators and particularly with defibrillator treatmenttherapy, the timer function may also be used in other patient caredecisions. Mild resuscitative hypothermia has been identified as atherapy that appears to be beneficial for patients with long down times.In addition to having a threshold value for CPR and defibrillationtherapy prompts, the defibrillator could also have a threshold timevalue for hypothermia therapy. A device configured in this manner mayprovide a prompt for immediate defibrillation if the response time isless than a first time (e.g. five (5) minutes, or approximately four (4)to approximately six (6) minutes), a prompt for CPR first if theresponse time is more than the first time but less than a second time(e.g. ten (10) minutes, or approximately nine (9) to approximatelyeleven (11) minutes), and a prompt for hypothermia therapy (or otheradvanced care) if the time is greater than the second time (e.g. ten(10) minutes). Hypothermia therapy would likely be provided by trainedACLS personnel or by hospital staff.

There is shown in FIG. 8 a flow chart that illustrates an embodiment ofa controller configuration that includes a hypothermia therapy. In afirst step a timer is started, step 81, and there follows a sample ofthe timer, step 82. (Various steps involving activating thedefibrillator and attaching electrodes to the patient are omitted.) Thesampled time is compared to a first threshold time, step 83. If thesampled time is less, a defibrillation protocol is ordered, step 84. Ifthe sampled time is greater, a second test (step 85) is performed.There, the sampled time is compared to a second threshold time. If thesampled time is less than the second threshold time, a CPR protocol isordered, step 86. If, however, the sampled time is greater than thesecond threshold time, a hypothermia protocol is ordered, step 87. Asbefore, cases in which the sampled time is equal to a threshold time maybe treated following one or the other of the options.

Still another emergency treatment decision involves rescue breathing.Some medical research suggests that patients who have been in cardiacarrest for a relatively short duration receive relatively little benefitfrom rescue breathing therapy. Thus, while performing CPR on thesepatients the caregiver would perform only chest compressions.Eventually, if circulation and spontaneous breathing is not restored,rescue breathing should be done. The timer function can be used toprovide appropriate prompts and indications to the caregiver so that heperforms the proper proportion of breaths and chest compressions. Theresuscitation timer would have a threshold value that would determinewhether it is appropriate to perform chest compressions only or to dobreaths as well. Still another emergency medical treatment decisioninvolves duration of CPR. AEDs normally have a particular time duration(X) for CPR programmed into them (or sometimes two CPR duration lengths,X and Y). In some devices, these CPR duration lengths are implementedvia voice prompts to instruct the rescuer to provide X seconds of CPRafter a “no shock advised” prompt or Y seconds of CPR after delivery ofthe last shock in a stack of shocks. In the case of a patient who hasbeen down for an elapsed time greater than some threshold, it may bedesirable to set the CPR duration to be longer than otherwise would bethe case. For example, a device that would nominally deliver promptsaiming to provider 60 seconds of CPR after a “no shock advised”decision, would issue prompts aimed to provide for 90 seconds when theelapsed time is greater than a first threshold value T1 but less than asecond threshold value T2, and 120 seconds when the elapsed time isgreater than a second threshold value T2, where T1<T2. The 90 second and120 second CPR durations are examples only. Other durations, such as,for example, 120 seconds for elapsed time >T1 (but less than T2), and180 seconds for elapsed time >T2. Elapsed time may also be used inmaking a decision on whether to prompt for a pulse check in somecircumstances. The prompt for pulse check could be eliminated inappropriate cases where the elapsed time since onset of the patient'semergency condition results in a situation where a pulse check will beof little to no benefit to the patient, but would delay subsequent stepsin the treatment protocol. In such cases, the elapsed time measurementcan be used to decide whether to eliminate the prompt for pulse check ina specific rescue situation.

Still another emergency treatment decision involves administration ofdrugs to the patient. Some drugs would be helpful to a patient who hasbeen in cardiac arrest for a relatively long time, but would be far lesshelpful if the time since onset of cardiac arrest has been relativelyshort (or vice versa). For patients who have been in an emergencycondition such as cardiac arrest a very long time, aggressive drugtherapy may be more appropriate than it would be for another patient whohas been in the condition for a shorter time period. Decisions onwhether and how to administer drugs such as epinephrine, vasopressin oramiodarone may be modified based on elapsed time since onset of thepatient's emergency condition. Long down-time patients may benefit fromdrug application before or simultaneous with defibrillation therapy.

In view of the foregoing, it should be appreciated that methods andapparatus are available that allow a defibrillator to be configured suchthat a timer function records a time between the activation of thedefibrillator at the onset of an emergency and the disposition of thedefibrillator at the patient's side. The defibrillator may use the timerfunction to determine an optimal patient therapy. While a finite numberof exemplary embodiments have been presented in the foregoing detaileddescription of the invention, it should be appreciated that a vastnumber of variations exist. It should also be appreciated that theexemplary embodiments are only examples, and are not intended to limitthe scope, applicability, or configuration of the invention in any way.Rather, the foregoing detailed description will provide those skilled inthe art with a convenient road map for implementing exemplaryembodiments of the invention. It being understood that various changesmay be made in the function and arrangement of elements described in anexemplary embodiment without departing from the scope of the inventionas set forth in the appended claims.

1-49. (canceled)
 50. An external defibrillator for providing a selectedtreatment protocol to a patient comprising: a connection port capable ofreceiving electrodes, the electrodes being capable of being attached toa patient so as to provide patient data to the defibrillator; and acontroller coupled to the connection port, and configured to: receive anactivation command that has been generated externally from thedefibrillator, start a timer function responsive to the receivedactivation command, sample an elapsed time from the timer function, andorder a CPR protocol if the elapsed time is greater than a set time,else order a shock treatment protocol if the elapsed time is less thanthe set time.
 51. The defibrillator of claim 50, further comprising: anoutput device, and in which the elapsed time is output through theoutput device so as to be readable by a human user.
 52. Thedefibrillator of claim 50, further comprising: a selectable overridefunction configured within the controller that immediately orders theshock treatment protocol when selected.
 53. The defibrillator of claim50, in which the controller is further configured to sense a patientconnection, and to sample the elapsed time in association with sensingthe patient connection.
 54. The defibrillator of claim 50, furthercomprising: a power on mode and an automatic power off mode, and inwhich the timer function continues to operate for a period of time afterthe defibrillator passes from power on mode to power off mode.
 55. Thedefibrillator of claim 50, further comprising: a low power circuit, andin which the timer function is operable through the low power circuit.56. The defibrillator of claim 55, further comprising: a power off andpower on mode, and in which the low power circuit remains active inpower off mode.
 57. The defibrillator of claim 50, further comprising: anon-volatile memory, and in which the controller is further configuredto: store in the non-volatile memory a start time associated with whenthe timer function is started, sample a second time, and sample theelapsed time by comparing the second time with the start time.
 58. Thedefibrillator of claim 57, further comprising: a real-time clockfunction, and in which the start time is recorded by sampling the clocktime, and the second time is also recorded by sampling the clock time.59. The defibrillator of claim 50, in which the controller is furtherconfigured so as to sense whether CPR is being administered to thepatient, and order a shock treatment protocol upon sensing that CPR isbeing administered to the patient.
 60. The defibrillator of claim 50, inwhich the controller is further configured to be instructed by a user tobypass ordering one of the CPR protocol and the shock treatment protocolbased on whether the elapsed time is greater or less than the set time,and to proceed directly to ordering the shock treatment protocol. 61.The defibrillator of claim 60, further comprising: an input device forthe user to enter the bypass instruction.
 62. The defibrillator of claim50, in which when the shock treatment protocol is ordered, thecontroller is further configured to: perform a shock analysis; order aCPR treatment protocol if shock treatment is not indicated by the shockanalysis; and issue a defibrillation shock if shock treatment isindicated by the shock analysis.
 63. The defibrillator of claim 50, inwhich the controller is further configured to offset the elapsed time byan adjustment value.
 64. The defibrillator of claim 63, in which theadjustment value is decoded from the activation command.
 65. Thedefibrillator of claim 50, in which the controller is further configuredto order hypothermia therapy if the elapsed time is greater than athreshold time which is longer than the set time.